a young boy with signs of puberty
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A boy with precocious puberty
Dr. Mashfiqul HasanResident, MD Phase A (EM)
Discipline of Endocrine MedicineBSMMU
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Case summary Short discussion
Overview
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Case summary
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7 year Boy Only child of parents
Particulars
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Appearance of pubic hair, facial hair Gradual enlargement of phallus Deepening of the voice
For 5-6 months
Presenting problems
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No history of headache, visual disturbance or seizure.
No significant past illness, no regular medication. No history of early onset puberty in family.
Other history
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Physical findings Pubic hair :
Slightly curled, dark, coarse, spread sparsely.
Tanner stage of pubic hair: P3
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Physical findings Testis: 15 ml on
both sides, firm, symmetrical, smooth surface
Stretched penile length: 12.5 cm
Tanner stage of genitalia: G4
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Height: 143 cm
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Current height : 143 cm Father’s height : 158 cm Mother’s height : 151 cm Expected adult height:
So, the expected adult height is : ◦ ` 161 cm (±10cm)
The target height
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Investigations
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Accelerated (>1 year)
Bone age
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S. Testosterone 4.9 nmol/L(0.1-1.0 nmol/l for 6-9 years)
S. LH 2.27 IU/L(0.01-0.78 nmol/l for 8-10 years)
S. FSH 3.26 IU/L(0.2–1.67 IU/L for 8-9 years)
Hormones
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LH spike (>10 mIU/ml) after 30 minutes.
GnRH stimulation test
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No significant abnormality.
MRI of brain
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Central idiopathic precocious puberty
Diagnosis
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Inj. Decapeptyl (11.25 mg) 3 monthly Plan is to continue up to 11 years of age Now he is on regular follow up
Treatment
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Discussion
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Pulsatile secretion of gonadotropin-releasing hormone (GnRH) and activation of the hypothalamo–pituitary–gonadal axis
Lower end of the normal range for the onset of puberty: ◦ 8 years in girls and ◦ 9 years 6 months in boys
Puberty
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Classification of precocious puberty
Central or Gonadotropin dependent
Peripheral or Gonadotropin independent
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Short adult stature due to early epiphyseal fusion,
Underlying pathology Adverse psychosocial outcomes
Physical & psychosocial problem
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Potential for progression
Evaluation of mechanism
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50% of cases regress or stop progressing, and no treatment is necessary
Evaluation is needed when◦Progression through pubertal stages◦Growth velocity ◦Bone age ◦LH peak after GnRH agonist
Progression of puberty
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Clinical Lab investigations
◦
Evaluation
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Family history Features of CNS lesion Testicular size Features of specific cause
Clinical evaluation
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S. Testosterone/S. Estradiol S. LH, S. FSH GnRH stimulation test S. ß-hCG S. DHEAS S. 17-hydroxy Progesterone Thyroid function test
Lab evaluation
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Pelvic ultrasound Testicular ultrasound MRI of brain
Imaging
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Management
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GnRH agonists◦Triptorelin (Decapeptyl)
Management of CNS lesion
Central precocious puberty
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Removal of the cause
Peripheral precocious puberty
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Social stigmata, psychosocial impact
Clinical dilemma Rational approach
Take home message
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Acknowledgement
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THANK YOU